2nd Scenario

A 19 years old woman, come to the emergency department at 23 o’clock, referenced by a

midwife in primary care with note : labor not advanced. On Anamnasis, we gain information
that the woman was pregnant for the first time, abdominal paint through the rear since 09
o’clock this morning with discharge of mucus and blood and at 21 o’clock the woman felt
straining, cervical opening 10 cm. The labor was conducted by the midwife but no progress.
On physical examination Fundus height 3 fingers below Xyphoideus processus, the fetus spine
was on the left side, the most lower part was head. Distance between Simphysis os pubis and
height of Fundus was 36 cm, Abdominal circumference 98 cm. Fetal Heart Rate 130x/minute,
His 4 times within 10 minutes with duration of 40-45 second. On intra vaginal examination,
cervical opening 10 cm, membranes not palpable, the position of the small crown in the lower
left , alightning match with Hodge 3.
1. DEFINE DIFFICULT WORDS
1. HIS: His is one of the forces in the mother that causes the cervix to open and push
the fetus down. In the presentation of the head, when his is strong enough, the head will
go down and into the pelvis
2. Hodge 3: The Hodge is studied to determine where the lowest part of the fetus
descends into the pelvis during labor. The Hodge III : this is parallel to the Hodge I and
II, located as high as the right and left ischial spines.

2. DEFINE KEYWORDS
 A 19 years old woman
 Labor not advanced
 First Pregnancy
 Abdominal pain trough the rear
 Discharge of mucus and blood, the woman felt straining, cervical opening 10
cm
 Distance beetwen Simphysis os pubis and height of fundus is 36 cm
 Fundus height 3 fingers below Xyphoideus processus
 Abdominal circumference 98 cm. Fetal Heart Rate 130x/minute, His 4 times
within 10 minutes with duration of 40-45 second. On intra vaginal examination,
cervical opening 10 cm, membranes not palpable, the position of the small
crown in the lower left , alightning match with Hodge 3.
3. DEFINE KEYWORDS WITH MAKING QUESTIONS:
1. How is sign of normal labor and not advance labor?
2. Explain factors that affect labor?
3. What are the hormone that takes part durig pregnancy?
4. What is the etiology of labor not advance?
5. How mechanism of normal labor?
6. What are the examination and observation needed in pregnancy?
7. How is dystocia treated?
8. What are the complications of obstructed labor in both mother and baby?
9. What is the Islamic perspective from the scenario?

2
3. ANSWER QUESTIONS:
1. How is sign of normal labor and not advance labor?
Sign of normal labor

1). The pain by the presence of his is stronger, frequent and regular
2). Mucus come out mixed with blood (show) a lot because of small tear on
the cervix.
3). Sometimes membranes rupture by itself
4) .On internal examination: cervix flattened and opening are present. (2)

When is the labor not advance

Labor not advance is a condition of a labor who is not advance and long-lasting
resulting in maternal and fetal complications (children). Prolonged labor is a
labor that lasts more than 24 hours for primigravida and / or 18 hours for multi
gravid. Labor is difficult to characterize with the progress of prolonged labor.
This situation occurs because of the abnormalities, which can be found singly
or in combination.
1. Abnormalities in the expulsion force, is the uterine forces are not strong
enough or uncoordinated appropriately to thinning and cervical dilatation
(uterine dysfunction) or inadequate voluntary muscle effort in the second
stage of labor

2. Abnormalities in the presentation, position or development of the fetus

3. Abnormalities of the mother's pelvis
4. Abnormalities in the birth canal so that inhibits the process of fetal decline.

References:

1. Mochtar, Rustam. 1998. Sinopsis Obstetri: Obstetri Fiologi/Obstetri

Patologi Edisi 2. Jakarta: ECG
2. Djalaluddin, Hakimi, Suharyanto,factor resiko ibu untuk terjadinya
partus lama di RSUD Ulin Banjarmasin dan RSU Ratu Zalecha
Martapura,Jurnal Sains Kesehatan, no.17 (1). Januari 2004.

2. Explain factors that affect labor?

Passages

Bony pelvis

The pelvis is made up of four bones:

•Two innominate bones.

3
•Sacrum.
• Coccyx.

The passage that these bones make can be divided into inlet, cavity and outlet

The pelvic inlet is bounded by the pubic crest, the iliopectineal line and the
sacral promontory. It is oval in shape, with its wider diameter being transverse.
The cavity of the pelvis is round in shape. The pelvic outlet is bounded by the
lower border of the pubic symphysis, the ischial spines and the tip of the sacrum.
Again the shape is oval, but the wider diameter is anteroposterior.

When a woman stands upright, the pelvis tilts forward. The inlet makes an angle
of about 55° with the horizontal; this varies between individuals and different
ethnic groups. The presenting part of the fetus must negotiate the axis of the
birth canal with the change of direction occurring by rotation at the pelvic floor.

Soft tissues

The soft passages consist of:

• Uterus (upper and lower segments).

4
• Cervix.
• Pelvic floor.
• Vagina.
• Perineum.

The upper uterine segment is responsible for the propulsive contractions that
deliver the fetus. The lower segment is the part of the uterus that lies between
the uterovesical fold of the peritoneum and the cervix. It develops gradually
during the third trimester, and then more rapidly during labour. It incorporates
the cervix as it effaces, to allow the presenting part to descend.

The pelvic floor consists of the levator ani group of muscles, including
pubococcygeus and iliococcygeus arising from the bony pelvis to form a
muscular diaphragm along with the internal obturator muscle and piriformis
muscle. As the presenting part of the fetus is pushed out of the uterus it passes
into the vagina, which has become hypertrophied during pregnancy. It reaches
the pelvic floor, which acts like a gutter to direct it forwards and allow rotation.
The perineum is distal to this and stretches as the head passes below the pubic
arch and delivers.

2. Passenger

The fetal skull consists of the face and the cranium. The cranium is made up of
two parietal bones, two frontal bones and the occipital bone, held together by a
membrane that allows movement. Up until early childhood, these bones are not
fused and so can overlap to allow the head to pass through the pelvis during
labour; this overlapping of the bones is known as moulding.

the anatomy of the fetal skull, including the sutures between the bones, and the
fontanelles. These are important landmarks that can be felt on vaginal
examination and enable the position of the fetus to be assessed. The position is
described in terms of the occiput in a cephalic presentation, and the sacrum in a
breech presentation.

5
The size and position of the fetal skull determine the ease with which the fetus
passes through the birth canal. The diameter that presents during labour depends
on the degree of flexion of the head. Thus the smallest diameters for delivery
are the suboccipitobregmatic diameter which represents a flexed vertex presen-
tation, and the submentobregmatic diameter, which corresponds to a face
presentation. The widest diameter is mentovertical, a brow presentation, which
usually precludes vaginal delivery.

3. Power

The myometrial component of the uterus acts as the power to deliver the fetus.
It consists of three layers

 Thin outer longitudinal layer.

 Thin inner circular layer.
 Thick middle spiral layer.

From early pregnancy, the uterus contracts painlessly and intermittently

(Braxton Hicks contractions). These contractions increase after the 36th week
until the onset of labour. In labour, a contraction starts from the junction of the
fallopian tube and the uterus on each side, spreading down and across the uterus
with its greatest intensity in the upper uterine segment.

During labour, the contractions are monitored for:

• Intensity.
• Frequency.
• Duration.

The resting tone of the uterus is about 6–12 mmHg; to be effective in labour this
increases to an intensity of 40–60mmHg. There are usually three or four
coordinated contractions every 10 minutes, each lasting approx 60 s, in order to
progress in labour.

6
 In the second stage of labour, additional power comes from voluntary
contraction of the diaphragm and the abdominal muscles as the mother pushes
to assist delivery.

Reference:
Milton SH, 2017, Normal labor and delivery, Department of Obstetrics and
Gynecology, Virginia Commonwealth University Health System

Prawirohardjo, Sarwono. 2016. Ilmu Kebidanan. Jakarta: PT. Bina Pustaka.

Edisi 4.
3. What are the hormone that takes part durig pregnancy?
HCG (Human Chorionic Gonadotrophin)
This hormone is produced by the embryo, at the time of implantation, the
embryo will stimulate the glands within the uterine wall to produce the hormone
HCG (Human Chorionic Gonadotropin). This hormone serves to stimulate the
corpus luteum to produce the hormones estrogen and progesterone. High HCG
levels in the first three months of pregnancy are thought to be the cause of
morning sickness. HCG hormone will be stable in the 2nd trimester.

Estrogen and Progesterone

This hormone is an important hormone in pregnancy. Both of these hormones
will cause the uterine wall to remain thick which is useful as implantation and
nurture the fetus. Progesterone prepares the lining of the uterus to receive an
ovum and stimulates the development of body tissues and gives a sense of calm.
Progesterone also prevents the uterus to contract during pregnancy before
reaching the time of birth. Along with estrogen, the hormone progesterone is
also useful to stimulate the development of mammary glands, enlarge breasts,
and make the areola widen and darker. The presence of estrogen hormones
inhibits the pituitary gland secretes FSH and LH, so the ovaries do not produce
an ovum anymore. That's why people who are pregnant do not get menstruation.
The placenta will secrete its own progesterone to maintain the pregnancy, in the
second trimester. The hormone estrogen is produced by the placenta with the
function of lowering the amount of the hormone progesterone so that
contraction of the uterine wall can take place.

Relaxin

7
This hormone softens the uterus and relaxes the pelvic muscles for the
preparation of birth. release by the corpus luteum and placenta.

Oxytocin
Oxytocin is produced in the hypothalamus, the posterior gland of the pituitary
"master gland" is all part of the human brain that works one of them to regulate
the endocrine system in the human body. This hormone is an important
reproductive hormone. This hormone is also very instrumental to stimulate and
strengthen uterine contractions during childbirth and pushing the fetus out. In
the postpartum period, oxytocin production can prevent bleeding by maintaining
uterine contractions, it is also useful to help the uterus contract to normal size
and stimulate milk production. Breast Milk (Mother's Milk) let-down reflex, the
reflex of breastfeeding, and this is strongly influenced by the hormone in the
body that is oxytocin at the time of breastfeeding.

Prostaglandin
The function of this hormone is stimulating pregnancy. Women produce this
hormone when the fetus is ready to be born. The semen fluid secreted by men
when ejaculation also contains prostaglandin hormones. The hormone
prostaglandins are produced by the extraembryonic membrane with the function
of increasing contraction of the uterine wall.
Endorphin
Endorphin hormones cause a sense of calm and relieve pain. This hormone
increases during pregnancy and peaks during labor / birth. Beta endorphin is
produced by the pituitary gland.

Prolactin
Produced by the anterior pituitary lobes that will stimulate the myoepithel and
cooperate with oxytocin stimulate the expenditure of breast milk. Release the
milk to spread out.

Reference:

Universitas Padjajaran. Endokrinologi Kehamilan dan Persalinan. Fakultas

Kedokteran: UNPAD. Bandung

8
4. What is the etiology of labor not advance?
Labor not advance is also called "dystocia", defined as abnormal / difficult
labor. The reasons can be divided into the following 3 groups.

• Abnormalities of energy (his deformity). His abnormalities in strength or

nature cause the usual birth canal disorders common in every labor, can not be
overcome so that labor experiences bottlenecks or congestion.

The types of abnormalities of his:

1. Uterine Inertia
Here it is common in the sense that the fundus contracts stronger and
earlier than the other parts, the role of the fundus remains prominent. The
disorder lies in the contraction of the uterus safer, shorter, and rarer than
usual. As long as the intact amniotic is generally harmless.

2. His Too Strong

Also called hypertonic uterine contraction. His being too strong and too
efficient causes labor to be completed in a very short time. Partus less than
3 hours is called the precipitous partus, the danger for the mother is the
widespread injury to the birth canal, especially the vagina and the
perineum. Babies may experience bleeding in the skull because the part is
under intense pressure in a short time.

3. Incoordinate uterine action

Here his nature changed. Uterine muscle tone increases, also outside of
his, and contractions do not go on as usual because there is no
synchronization of contractions of the parts. The absence of coordination
between upper, middle, and lower contours causes his inefficiency in
opening.

• Fetal abnormalities. Labor may be susceptible to interference or congestion

due to abnormalities in the location or in the form of the fetus.

• Abnormalities of the birth canal. Abnormalities in the size or shape of the

birth can prevent labor or cause congestion.

MALPRESENTATIONS
More than 95% of fetuses present with the vertex and are termed ‘normal’.
Those presenting with other parts of the body (breech, face, brow, shoulder,
cord) to the lower segment and cervix are known as malpresentations. There
may be a reason for malpresentation, although in most instances there is no
identifable cause. They also present with specifc problems in labour and during
delivery. In modern obstetrics the presentation needs to be diagnosed early in
labour and appropriate management instituted to prevent maternal or fetal
injury.

9
Face presentation
In face presentation the fetal head is hyperextended so that the part of the head
between the chin and orbits, i.e. The eyes, nose and mouth, that can be felt with
the examining fnger is the presenting part. The incidence is about 1 in 500
deliveries. In most cases the cause is unknown, but is associated with high parity
and fetal anomaly particularly anencephaly. In modern obstetric practice where
most pregnant women have an ultrasound scan for fetal abnormalities it is rare
to see such conditions as a cause of face presentation.

Brow presentation
A brow presentation is described when the attitude of the fetal head is midway
between a flexed vertex and face presentation and is the most unfavourable of
all cephalic presentations. The condition is rare and occurs in 1 in 1500 births.
If the head becomes impacted as a brow the presenting diameter, the
mentovertical diameter (13cm), is incompatible with vaginal delivery.

Compound presentation

Whenever an extremity, most commonly an upper extremity, is found prolapsed

beside the main presenting fetal part, the situation is referred to as a compound
presentation. Te reported incidence ranges from 1 in 377 to 1 in 1213 deliveries.
The combination of an upper extremity and the vertex is the most common. This
diagnosis should be suspected with any arrest of labor in the active phase or
failure to engage during active labor. Diagnosis is made on vaginal examination
by discovery of an irregular mobile tissue mass adjacent to the larger presenting
part. Recognition late in labor is common, and as many as 50% of persisting
compound presentations are not detected until the second stage. Delay in
diagnosis may not be detrimental because it is likely that only the persistent
cases require intervention. Although maternal age, race, parity, and pelvic size
have been associated with compound presentation, prematurity is the most
consistent clinical finding. The very small premature fetus is at great risk of
persistent compound presentation. In late pregnancy, ECV of a fetus in breech
position increases the risk of a compound presentation. Older, uncontrolled
studies report elevated perinatal mortality rates with a compound presentation,
with an overall rate of 93 per 1000. Higher loss rates of 17% to 19% have been
reported when the foot prolapses. As with other malpresentations, fetal risk is
directly related to the method of management. A fetal mortality rate of 4.8% has
been noted if no intervention is required compared with 14.4% with intervention
other than cesarean delivery. A 30% fetal mortality rate has been observed with
IPV and breech extraction. These figures may demonstrate selection bias
because it is possible that more often, the difficult cases were chosen for
manipulative intervention. When intervention is necessary, cesarean delivery
appears to be the only safe choice. Fetal risk in compound presentation is
specifically associated with birth trauma and cord prolapse. Cord prolapse
occurs in11% to 20% of cases, and it is the most frequent complication of this

10
malpresentation. Cord prolapse probably occurs because the compound
extremity splints the larger presenting part and results in an irregular fetal
aggregate that incompletely fills the pelvic inlet. In addition to the hypoxic risk
of cord prolapse, common fetal morbidity includes neurologic and
musculoskeletal damage to the involved extremity. Maternal risks include soft
tissue damage and obstetric laceration. Again, although laboring is not
proscribed, the prolapsed extremity should not be manipulated. However, it may
spontaneously retract as the major presenting part descends. Seventy-five
percent of vertex/upper extremity combinations deliver spontaneously. Occult
or obscured cord prolapse is possible, and there fore continuous electronic FHR
monitoring is recommended. The primary indications for surgical intervention
(i.e., cesarean delivery) are cord prolapse, nonreassuring FHR patterns, and
arrest of labor. Cesarean delivery is the only appropriate clinical intervention
for cord prolapse and nonreassuring FHR patterns because both version
extraction and repositioning the prolapsed extremity are associated with adverse
outcome and should be avoided. From 2% to 25% of com pound presentations
require cesarean delivery. Protraction of the second stage of labor and
dysfunctional labor patterns have been noted to occur more frequently with
persistent compound presentations. As in other malpresentations, spontaneous
resolution occurs more often, and surgical intervention is less frequently
necessary in those cases diagnosed early in labor. Small or premature fetuses
are more likely to have persistent compound presentations but are also more
likely to have a successful vaginal delivery. Persistent compound presentation
with parts other than the vertex and hand in combination in a termsized infant
has a poor prognosis for safe vaginal delivery, and cesarean delivery is usually
necessary. However, a simple compound presentation (e.g., hand) may be
allowed to labor, if labor is progressing normally with reassuring fetal status.

Breech presentation

The infant presenting as a breech occupies a longitudinal axis with the cephalic
pole in the uterine fundus. Tis presentation occurs in 3% to 4% of labors overall,
although it is found in 7% of pregnancies at 32 weeks and in 25% of pregnancies
of less than 28 weeks’ duration.10. The infant in the frank breech position is
flexed at the hips with extended knees (pike position). The complete breech is
flexed at both joints (tuck position), and the footling or incomplete breech has
one or both hips partially or fully extended. The diagnosis of breech presentation
may be made by abdominal palpation or vaginal examination and confirmed by
ultrasound. Prematurity, fetal malformation, müllerian anomalies, and polar
placentation are commonly observed causative factors. High rates of breech
presentation are noted in certain fetal genetic disorders, including trisomies 13,
18, and 21; Potter syndrome; and myotonic dystrophy. Conditions that alter fetal
muscular tone and mobility—such as increased and decreased amniotic fluid,
for example—also increase the frequency of breech presentation. Te breech

11
head appears dolichocephalic on ultrasound, and for that reason, the biparietal
diameter (BPD) appears small. However, the head circumference remains
unaffected. Tis difference may be as much as 16+ days (95% confdence interval
[CI], 14.3 to 18.1; P = .001).1Whereas thecontracted BPD may affect
ultrasound-determined weight estimates of the fetus, an occipitofrontal diameter
(OFD) to BPD ratio of greater than 1.3 in the absence of other indicators of
growth delay signals the deformation characteristic of thebreech-presenting
fetus. Approximately 80% of breech fetuses will have a dolichocephalic
contour, previously termed the “breech head.”12 Te fundus of the uterus
assumes a more elongated contour than the bowl-like developed lower uterine
segment. Tus it is believed that forces external to the fetus are responsible for
this head shape. Because both dolichocephaly and breech may be associated
with a genetically and phenotypically anomalous fetus, it behooves the
sonologist to perform a detailed survey of the fetal anatomy prior to assuming
the presence of the “breech head.”

MALPOSITION OF THE FETAL HEAD

Position of the fetal head is defned as the relationship of the denominator to the
fxed points of the maternal pelvis. The denominator of the head is the most
defnable prominence at the periphery of the presenting part. In 90% of cases,
the vertex presents with the occiput in the anteriorhalf of the pelvis in late labour
and hence is defned as ‘normal’ or ‘occipitoanterior’ (OA) position. In about
10% of cases there may be malposition of the head, i.e. The occiput presents in
the posterior half of the pelvis with the occiput facing the sacrum or one of the
two sacroiliac preferable to proceed to caesarean section. In cases of joints – the
occipitoposterior (OP) position, or the sagittal
suture is directed along the transverse diameter of the pelvis – the
occipitotransverse (OT) position. Malposition of the vertex is frequently
associated with deflexion of the fetal head or varying degrees of asynclitism, i.e.
One parietal bone, usually the anterior, being lower in the pelvis with the
parietal eminences at different levels. Asynclitism is most pronounced in the
OT position. Deflexion and asynclitism are associated with larger presenting
diameters of the fetal head thereby making normal delivery more diffcult.

The occipitoposterior position

Some 10–20% of all cephalic presentations are OP positions at the onset of
labour either as a direct or, more commonly, as an oblique right or left OP
position. During labour the head usually undertakes the long rotation through
the transverse to the OA position but a few, about 5%, remain on the OP
position. Where the OP position persists, progress of the labour may be arrested
due to the deflexed attitude of the head that results in larger presenting diameters
(11.5cm × 9.5cm) than are found with OA positions (9.5cm × 9.5cm). Prolonged

12
 and painful labour
associated with backache are characteristic feature of a posterior fetal position.

Deep transverse arrest

The head normally descends into the pelvis in the OT or OP position and then
the occiput rotates nteriorly to emerge under the pubic arch. Occasionally this
anterior rotation of the occiput fails to occur or, in an OP position, fails to rotate
beyond the transverse diameter of the pelvis. Labour will then become arrested
due to the large presenting diameters resulting from asynclitism of the head that
characterizes a fetal OT position. This clinical situation is
referred to as ‘deep transverse arrest’.

Reference:
Prawirohardjo, Sarwono. 2016. Ilmu Kebidanan. Jakarta: PT. Bina Pustaka.
Edisi 4. Hal 562-569
Rachel A. Pilliod, MD, Aaron B. Caughey, MD, PhD. Fetal Malpresentation
and Malposition Diagnosis and Management. Department of Obstetrics and
Gynecology, Oregon Health & Science University. USA: Elsavier. Clinicalkey.
Page 635
Symonds, Ian, MB BS MMedSci DM FRCOG FRANZCOG; Arulkumaran,
Sabaratnam, Sir. Essential Obstetrics and Gynaecology, Fifth Edition; Chapter
12 Management of delivery Elsavier, Clinical Key. Page 187-188

5. How mechanism of normal labor?

Stages of Labor
Obstetricians have divided labor into 3 stages that delineate milestones in a
continuous process.

First stage of labor

The first stage begins with regular uterine contractions and ends with complete
cervical dilatation at 10 cm. In Friedman’s landmark studies of 500 nulliparas,
he subdivided the first stage into an early latent phase and an ensuing active
phase. The latent phase begins with mild, irregular uterine contractions that
soften and shorten the cervix. The contractions become progressively more
rhythmic and stronger. This is followed by the active phase of labor, which
usually begins at about 3-4 cm of cervical dilation and is characterized by rapid
cervical dilation and descent of the presenting fetal part. The first stage of labor
ends with complete cervical dilation at 10 cm. According to Friedman, the active
phase is further divided into an acceleration phase, a phase of maximum slope,
and a deceleration phase.

Characteristics of the average cervical dilatation curve is known as the Friedman

labor curve, and a series of definitions of labor protraction and arrest were

13
subsequently established. However, subsequent data of modern obstetric
population suggest that the rate of cervical dilatation is slower and the
progression of labor may be significantly different from that suggested by the
Friedman labor curve.

Second stage of labor

The second stage begins with complete cervical dilatation and ends with the
delivery of the fetus. The American College of Obstetricians and Gynecologists
(ACOG) has suggested that a prolonged second stage of labor should be
considered when the second stage of labor exceeds 3 hours if regional anesthesia
is administered or 2 hours in the absence of regional anesthesia for nulliparas.
In multiparous women, such a diagnosis can be made if the second stage of labor
exceeds 2 hours with regional anesthesia or 1 hour without it.

Studies performed to examine perinatal outcomes associated with a prolonged

second stage of labor revealed increased risks of operative deliveries and
maternal morbidities but no differences in neonatal outcomes. Maternal risk
factors associated with a prolonged second stage include nulliparity, increasing
maternal weight and/or weight gain, use of regional anesthesia, induction of
labor, fetal occiput in a posterior or transverse position, and increased
birthweight.

Third stage of labor

The third stage of labor is defined by the time period between the delivery of
the fetus and the delivery of the placenta and fetal membranes. During this
period, uterine contraction decreases basal blood flow, which results in
thickening and reduction in the surface area of the myometrium underlying the
placenta with subsequent detachment of the placenta. Although delivery of the
placenta often requires less than 10 minutes, the duration of the third stage of
labor may last as long as 30 minutes.

Expectant management of the third stage of labor involves spontaneous delivery

of the placenta. Active management often involves prophylactic administration
of oxytocin or other uterotonics (prostaglandins or ergot alkaloids), cord
clamping/cutting, and controlled cord traction of the umbilical cord. Andersson
et al found that delayed cord clamping (≥180 seconds after delivery) improved
iron status and reduced prevalence of iron deficiency at age 4 months and also
reduced prevalence of neonatal anemia, without apparent adverse effects.

A systematic review of the literature that included 5 randomized controlled trials

comparing active and expectant management of the third stage reports that
active management shortens the duration of the third stage and is superior to
expectant management with respect to blood loss/risk of postpartum
hemorrhage; however, active management is associated with an increased risk

14
of unpleasant side effects.

The third stage of labor is considered prolonged after 30 minutes, and active
intervention, such as manual extraction of the placenta, is commonly
considered.

Mechanism of Labor
The ability of the fetus to successfully negotiate the pelvis during labor involves
changes in position of its head during its passage in labor. The mechanisms of
labor, also known as the cardinal movements, are described in relation to a
vertex presentation, as is the case in 95% of all pregnancies. Although labor and
delivery occurs in a continuous fashion, the cardinal movements are described
as 7 discrete sequences, as discussed below.

Engagement
The widest diameter of the presenting part (with a well-flexed head, where the
largest transverse diameter of the fetal occiput is the biparietal diameter) enters
the maternal pelvis to a level below the plane of the pelvic inlet. On the pelvic
examination, the presenting part is at 0 station, or at the level of the maternal
ischial spines.

Descent
The downward passage of the presenting part through the pelvis. This occurs
intermittently with contractions. The rate is greatest during the second stage of
labor.

Flexion
As the fetal vertex descents, it encounters resistance from the bony pelvis or the
soft tissues of the pelvic floor, resulting in passive flexion of the fetal occiput.
The chin is brought into contact with the fetal thorax, and the presenting
diameter changes from occipitofrontal (11.0 cm) to suboccipitobregmatic (9.5
cm) for optimal passage through the pelvis.

Internal rotation
As the head descends, the presenting part, usually in the transverse position, is
rotated about 45° to anteroposterior (AP) position under the symphysis. Internal
rotation brings the AP diameter of the head in line with the AP diameter of the
pelvic outlet.

Extension
With further descent and full flexion of the head, the base of the occiput comes
in contact with the inferior margin of the pubic symphysis. Upward resistance
from the pelvic floor and the downward forces from the uterine contractions
cause the occiput to extend and rotate around the symphysis. This is followed

15
 by the delivery of the fetus' head.

Restitution and external rotation

When the fetus' head is free of resistance, it untwists about 45° left or right,
returning to its original anatomic position in relation to the body.

Expulsion
After the fetus' head is delivered, further descent brings the anterior shoulder to
the level of the pubic symphysis. The anterior shoulder is then rotated under the
symphysis, followed by the posterior shoulder and the rest of the fetus.

Reference
Author
Milton SH, 2017, Normal labor and delivery, Department of Obstetrics and
Gynecology, Virginia Commonwealth University Health System

6. What are the examination and observation needed in pregnancy?

Focused antenatal care (ANC): the four visit ANC model outlined in WHO
clinical guidelines.

GOALS
First visit Second visit Third visit Fourth visit
8-12 weeks 24-26 weeks 32 weeks 36-38 weeks
Confirm pregnancy Asses maternal and Asses maternal and Asses maternal and
and EDD, classify fetalwell-being. fetal well-being. fetal well-being.
women for basic Exclude PIH and Exclude PIH, Exclude PIH,
ANC (four visit) or anemia. Give anemia, multiple anemua, multiple
more specialized preventive measures. pregnancies. Give pregnancies,
care, screen, treat, Review and modify preventive malpresentation.
and give preventive birth and emergency measures. Review Give preventive
measures. Develop a plan. Advise and and modify birth and measures. Review
birth and emergency counsel. emergency plan. and modify birth and
plan. Advise and Advise and counsel. emergency plan.
counsel. Advise and counsel.

ACTIVITIES
First visit Second visit Third visit Fourth visit
8-12 weeks 24-26 weeks 32 weeks 36-38 weeks
History Asses Asses Asses Asses
significant significant significant significant
symptoms. Take symptoms. symptoms. symptoms.
psychosocial, Check record Check record Check record
medical and for previous for previous for previous

16
 obstetric complications complication complication
history. Confirm and treatments and treatments and treatments
pregnancy and during the during the during
calculate EDD. pregnancy. Re- pregnancy. Re- pregnancy. Re-
Classify all classification if classification if classification if
women. needed. needed. needed.
Examination Complete Anaemia, BP, Anaemia, BP, Anaemia, BP,
(inspection, general, and fetal growth, fetal growth, fetal growth and
auscultation, obstetrical and movement. multiple movement,
palpation)* examination, BP pregnancy. multiple
pregnancy,
malpresentation
Screening and Haemoglobin Bacteriuria Bacteriuria Bacteriuria
tests Syphilis
HIV
Proteinuria
Blood/Rh group
Bacteriuria
Treatments Syphilis Antihelminthic ARV if eligible ARV if eligible
ARV if eligble ARV if eligible Treat bacteriuria If breech, ECV
Treat bacteriuria Treat bacteriuria if indicated or referral for
if indicated if indicated ECV
Treat bacteriuria
Preventive Tetanus toxoid Tetanus toxoid Iron and folate Iron and folate
measures Iron and folate Iron and folate IPTp ARV
IPTp ARV
ARV
Health Self-care, Birth and Birth and Birth and
education alcohol, and emergency plan, emergency plan, emergency
advice, and tobacco use, reinforcement infant plan,infant
counseling nutrition, safe of previous feeding,post feeding, post
sex, rest, advice. partum care, partum care,
sleeping under pregnancy pregnancy
ITN, birth and spacing, spacing,
emergency plan. reinforcement reinforcement
of previous of previous
advice advice

PHYSICAL EXAMINATION

I. General Examination
The obstetric examination begins by looking at the patient. Pay particular
attention to:
 General appearance – fatigue/exhausted, anxious, depressed, nausea

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 Does she appear pallor or breathlessness?
 Does she have difficulty getting up and walk from the waiting room to the
clinic room?

Measure the mother’s height and weight if this has not been done. Generally:
 Smaller women tend to have smaller babies
 Patients with a high BMI are more likely to develop gestational diabetes,
macrosomnia, and polyhydramnios

Measure the mother’s blood pressure and check her urine dipstix if this has not
been done. This is to identify:
 Hypertension
 Proteinuria
 Glucosuria
 UTIs

II - Inspection
On inspection, there are 5 signs that you should focus on.

Size
 The uterus is normally visible in the abdomen at 12-14 weeks of gestation
 It will reach the level of the umbilicus at around 20 weeks of gestation
 The uterus will reach maximum height at the level of the xiphisternum at
36 weeks

Note: the size and shape of the uterus should be regular and symmetrical
unless there are multiple pregnancies or polyhydramnios.

Scars
 The most important scar to look for is the Pfannenstiel scar, which is a
transverse scar across the lower abdomen. The Pfannenstiel scar indicates
a previous Caesarean-section.
 Other scars to look for are laparoscopic scars and laparotomy scars, if
indicated in the patient’s previous surgical history.

Skin Changes
 Striae gravidarum, or stretch marks, are caused by pregnancy hormones of
the current pregnancy. They appear red and inflamed and occur early in the
pregnancy. Patients may complain of discomfort and pruritus around the
area.
 Striae albicantes are stretch marks from previous pregnancies. They appear
as white and silvery. These stretch marks are more common in the lower
abdomen, upper thighs and buttocks.
 Linea nigra is the hyperpigmentation of the midline linea alba. Similarly,
the hyperpigmentation is caused by the pregnancy hormones of the current
pregnancy.

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Fetal movements
 Fetal movements are visible after 24 weeks – which can be used as a way
to confirm viability of the fetus

Umbilicus
 The umbilicus becomes flattened as the pregnancy progresses to term (i.e.
normal).
 May become flattened and everted in multiple pregnancy and
polyhydramnios.

III - Palpation
Palpation of the pregnant abdomen must be gentle and careful, as pregnant
woman can be quite sensitive about the health of the fetus. It is quite useful to
start with a general palpation of the four quadrants of the abdomen. However,
before you place your hands on the abdomen, always ask about areas of pain
and tenderness. As a general rule: always palpate these areas last.

The palpation of the abdomen serves several purposes; by the end of palpation,
you should be able to comment on:

 Fetal growth
 Liquor volume
 Multiple pregnancies
 Fetal lie and presentation

There are 4 steps in palpating the pregnant abdomen (also called Leopold’s
Manoeuvers):

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Maneuver 1
Fundal height (i.e. uterine size and, consequently, gestational age) and
the fetus part lied at the fundus is determined placing both palms horizontally,
above the uterine fundus.

Maneuver 2
The examiner move his/her palms from the fundus to the lateral parts of
the uterus and palpate the fetus parts facing to lateral uterine walls with right
and left hands alternately. In polar presentation, the fetal back can be palpated
as a wide smooth surface; on the other side, the fetal extremities are palpated as
small irregularities and protrusions. Thus, this maneuver attempts to determine
the fetal location, position and type.

Maneuver 3
The examiner shall grasp the presenting part of the fetus with one hand
(generally the right one) which is placed slightly above the pubis, making soft
rightward and leftward movements. The fetal head is felt as a solid globular part
with sharp outlines. If the fetal head has not been at the inlet or lower
abdomen yet, it easily moves balloting among other fingers. In the breech
presentation, the volumetric softish part is determined; it is not round and can
not ballot. In shoulder presentation or oblique lie, the presenting part can not be
palpated. Thus, maneuver 3 attempts to determine the presenting part nature and
its position to the inlet or lower abdomen.

Maneuver 4
Supplements the previous one and helps to determine the presenting part
and the level of its position to the inlet or lower abdomen. The examiner shall
face the women feet, put both palms on the lateral lower uterus segments, and
palpate the accessible fetal presenting parts trying to reach between the
presenting part and lateral small pelvic inlet with his/her finger tips. The forth
maneuver attempts to determine the degree of the fetal head fitting into the small
pelvis. If the head places high and moves above the small pelvic inlet, the finger
tips can be almost fully placed under the head. If the head came down into the
small pelvis, the finger tips can not meet between the head and the inlet. If the
hand slide along the inserted head (with hand divaricating above the head), the
minor segment of the head is in the inlet; if the hands meet above it, the major
segment of the head is in the inlet; if the head has significantly come in the
pelvic cavity, only the fetal head base can be palpated above the inlet.

IV - Percussion and Auscultation

Percussion

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There is no significance of percussion in the examination. However, if you
suspect polyhydramnios, you can confirm by a showing a positive fluid thrill
with a negative shifting dullness.
Auscultation
You will need a hand-held Doppler monitor or a Pinard stethoscope. It is
recommended that you should use a Pinard stethoscope after 28 weeks.
1. Place the Doppler transducer or the Pinard stethoscope over the anterior
shoulder, usually between the symphysis pubis and the umbilicus.

Interpretation: the fetal heart rate is between 110-160 b.p.m. You can
simultaneously feel for the maternal’s radial pulse to distinguish between
the two individuals.

V - Internal Examination

Vaginal examination should only be carried out in later pregnancy to allow

assessment of the favourability of the cervix for labour and delivery. In early
pregnancy, vaginal examination not only increases the risk of ascending
infection but also may cause antepartum haemorrhage (e.g., in the case of
placentae praevia).
1. Inspect the vulva. Examine for any vaginal discharge and note any
abnormalities such as varicosities.
2. Examine the vagina and cervix using a sterile Cusco’s speculum through an
aseptic technique.
3. Identify the cervix and determine:
o Dilation of the cervix – assess using examining fingers. This is one of
the examinations where knowing the breadth of your finger comes into
use. Note the breadth of your index finger on your examining hand.
Generally, it is about 1 – 1.5 centimeters.
o Cervical length – normally, the cervix is about 3 – 3.5 cm. However,
during labor, the cervix effaces and contracts, which shortens the overall
length.
o Consistency – describes the softness of the cervix: firm, medium, or soft.
o Position – the position of the cervix changes during labour as it effaces
and contracts. The cervix is pulled anteriorly as labour progresses.
o Station – refers to the level of the presenting part in relation to the ischial
spines. The station is negative if it is above the ischial spines and positive
if it is below the ischial spines (e.g., -3 means that the level of the head
is 3 cm above the ischial spines; whereas, +3 means the head is 3 cm
below). The station of the presenting part should coincide with the
engagement of the head determined in the Third Manoeuver.

Interpretation: the Bishop score, which encompasses the 5

characteristics mentioned, is used as an assessment tool to evaluate the
favourability of the cervix for vaginal delivery. Be familiar with the
Bishop scoring system, although it is unlikely that you will be asked to
perform an internal examination of the vagina.

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 References:
1. Lincetto,Ornella. 2017. Antenata Care. World Health Organization.
2. Dnepropetrovsk Medical Academy. 2014. Obstetric and Gyneacology
Examination.
3. Douglas G, Nicol F, Robertson C (eds). Macleod’s Clinical Examination.
11th ed. Churchill Livingstone. 2009
4. Beckman C, Ling F et al [in collaboration with ACOG]. Obstetrics and
Gynecology. 6th ed. Lippincott Williams and Wilkins. 2009

7. How is dystocia treated?

In the face of prolonged labor, no matter what the circumstances of the mother
concerned should be carefully monitored. blood pressure is measured every four
hours, even this examination needs to be done more often if there is a state of
preeclampsia. Fetal heart rate is recorded every half hour in the first stage and more
often in the second stage. The possibility of dehydration and acidosis should be given
full attention. Because there is a long labor there is always the possibility to perform
surgery with narcosis, the mother should not be fed normally but in the form of fluids.
Preferably the infusion of 5% glucose solution and intravenous isotonic NaCl
solutions are alternated. To reduce the pain may be given repeated petmine 50 mg; at
the beginning of the first stage I may be given 10 mg of morphine. An in-depth
examination needs to be done, but it should always be realized that any examination
in the presence of an infection hazard. If labor is 24 hours without significant progress,
careful assessment of the circumstances is necessary. In addition to the general
assessment of circumstances, it is necessary to determine whether labor is actually
starting or still within the false-labor level, whether there is uterine inertia or
incoordinate uterine action; and whether there is no cephalopelvik disproportion even
mild. To determine this latter, if necessary pelvimetry roentgenologik or Magnetic
Resonance Imaging (MR). If the cervix is already open for at least 3 cm, it can be
concluded that labor has begun. In determining the further attitude to know whether
the membranes have been or have not broken. If the membranes are ruptured, then the
decision to complete labor should not be delayed too long due to the danger of
infection. Preferably within 24 hours of ruptured membranes a decision can be made
whether cesarean section is necessary in a short time or labor may be allowed to
continue.

Operation that can we doing if dystocia happening:

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 Reference:

 Prawirohardjo, Sarwono. 2016. Ilmu Kebidanan. Jakarta: PT. Bina Pustaka. Edisi
4. Hal 566-567.
 Modified from Johanson RB, Menon BK. Vacuum extraction versus forceps for
assisted vaginal delivery. Cochrane Database. Elsavier, Clinical Key.

8. What are the complications of obstructed labor in both mother and baby?
The impact of prolonged labor on the mother
1. Intrapartum infections
Infection is a serious danger that mom and dad use on old partus, especially if breakfast
is an infection. Bacteria in the amniotic fluid penetrate the amnion and invade the
decidua and also the chorionic thread has been bakterimia and sepsis in the mother and
fetus. Fetal pneumonia, the result of infected amniotic fluid aspiration, is another
serious consequence.
2. Uter rupture
The abnormal depletion of the lower uterine segment poses a danger during the ama
partus, especially in mothers with high parity and in those with a history of SC. If there
are no heads and capabilities, there is no limit, the segments below the uterus become
so overwhelming that it can cause rupture. In this case a pathological retraction ring
may be created.
The pathological retraction ring is the formation of an abnormally normal retraction
ring. The often-appearing rings are inhibited, defective stretching and thinning at the
bottom of the uterus.
3. Formation of Fistulas
If the lower part of the fetus towards the top of the pelvis, but not advanced for long
periods of time, parts that can be used and excess. Due to impaired circulation, necrosis
may occur which will be apparent within a few days after delivery with the birth of a
vesicovaginal, vesicosevical, or retovaginal fistula. Delivery of necrosis at present in
prolonged second-stage prognosis.
Effects on Fetus
The old Partus itself can be detrimental. When the pelvis is narrow and there is also an
old rupture of membranes and intrauterine memories, the number of fetuses and mother
will appear. Intrapartum infection is not only a serious complication in the mother, but
also an important thing of infant and neonatal death. This is called bacteria in the
amniotic fluid of bacteremia in the mother and fetus. Fetal pneumonia, due to aspiration
of amnionic fluid infected, is another serious consequence.
1. Kapsedaneum Kaput

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 When the pelvis is narrow, during labor there is often a large succulent kaput in the
lower part of the fetal head. This can be quite large and produces serious diagnostic
discomfort. Caput can be quite large and cause serious diagnostic errors. Kaput can find
the pelvic floor while the head itself is not yet capable. Lesser physicians can make
premature and unwise efforts to extract forceps. Ordinary capuk succedaneum, even
large ones, will disappear within a few days.
2. Fetal Head Molasses
As a result, he is strong, skull bones that overlap each other in large sutures, then a
process called moase (printing). Usually the median border of the parietal bone in
contact with the promontory overlaps with the bone next to it; the same thing happens
to the frontal bones. However, the occipital bone is pushed down the parietal bone.
Changes-often occur without causing any real loss. In other parts of the distortion,
molasses can cause tentorium rupture, fetal vascular laceration, and intracranial
haemorrhage in the fetus.
Sorbe and Dahlgren measured the diameter of the fetal head at birth and compared it
with measurements taken 3 days later. Most bacillary molasses occur in the
suboxypitobregmatic diameter and mean comprehension of 0.3 cm with a range of up
to 1.5 cm. Biparietal diameter is not affected by fetal head molasses. Factors associated
with molasses are nulliparity, labor stimulation with oxytocin, and fetal transmission
by vacuum extraction. Carlan et al. Reports a locking hazard (locking mechanism)
when the skull spine is pushed in the other direction, more and possibly protects the
fetal brain. They also observed that a head can occur before delivery. The Netherlands
saw that the true molasses could cause fatal subdural hemorrhage due to the tearing of
the septum durameter, especially in the tentatum of the serbeli. Such ROBs are present
either in labor with normal show or labor.
Along with molasses, the parietal bones that come into contact with the promontory,
give signs of a great mendaapt, sometimes even flat. Easier to do, the head bones have
not been through a perfect ossification. This important process may be one of the
explanations in the labor process of two cases that resemble the sizes of the pelvis and
the identical head.

Source: Prawirohardjo, sarwono. Ilmu Kebidanan. P.T Bina Pustaka Sarwono

Prawirohardjo. Jakarta. 2016.

9. What is the Islamic perspective from the scenario?

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And We have enjoined upon man [care] for his parents. His mother carried him,
[increasing her] in weakness upon weakness, and his weaning is in two years.
Be grateful to Me and to your parents; to Me is the [final] destination.

Reference:
Holy Quran Al Lukman:14

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